Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.

In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. The average ED is in a community hospital, and sees fewer than 100 patients a day. This community hospital ED will likely not be designated a Level I trauma center, and the practicing physician will have to make decisions on complicated patients without all of the resources and consultants available at a tertiary care medical center. He will have to make these decisions alone. Given that most graduating emergency medicine residents will practice in such a setting, we should ask ourselves is this the best we can do? Does the current training model best prepare the emergency medicine resident for the kind of practice he will enter

I noticed this myself, first job out of residency. I could do trauma in my sleep, but had a very steep learning curve at a place with high-end (and high-expectation) cardiology groups.

The reality that in ‘the real world’ there were no surgical consultations, they just wanted to know one thing: do I need to operate or not? Also in the real world, going from a strong-hand department where the ED was regarded as the best residency with the best residents to being the new guy and the ED is the Repository of All Hospital Guilt, so no matter how thorough you were, the inpatient disaster was phrased so as to be something missed by the ER doc, and not the admitting team.

I did rotate (for one month, at the end of my residency) at a somewhat lower volume community ED, but there’s only so much to be learned while being a visitor for 18 shifts.

This doesn’t mean my trainers were lazy, or bad; it’s the reality that the hospital paying our salaries had expectations we’d be able to see the patients in that joint.

(This is, by the way, one of the better things about moonlighting as an EM resident; stretch yourself, find out what you don’t know while you still have time to learn. We moonlit at a place about 45 minutes from our Big Center, so there was a safety net to catch us…) Moonlighting is now Verboten, so there’s another door closed.

I’d like to see the residencies in EM move to decentralize from one place, and give a more rounded experience. Not going to happen, but it would be nice.